Value of a Community-Based Medication Management

Review Service in Jordan: A Prospective Randomized

Controlled Study
Iman A. Basheti,1 Odate K. I. Tadros,2 and Salah Aburuz,2,3,*
1
Department of Clinical Pharmacy, Faculty of Pharmacy, Applied Sciences University Amman, Jordan;
2
Department of Biopharmaceutics & Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman,
Jordan; 3College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

STUDY OBJECTIVE To assess the impact of a medication management review (MMR) service on treat-
ment-related problems (TRPs) and certain clinical outcomes in outpatients.
DESIGN Prospective randomized controlled study.
SETTING Two community pharmacies in Amman, Jordan.
PATIENTS A total of 160 people who visited the two community pharmacies between September 2009
and June 2010.
INTERVENTION Patients were randomized into two groups: intervention (82 patients) and control (78
patients) groups. The clinical pharmacist conducted a baseline assessment MMR for patients in both
groups to determine the prevalence and type of TRPs; however, recommendations regarding the
identified TRPs were only submitted to the physicians of patients in the intervention group.
MEASUREMENTS AND MAIN RESULTS All patients were followed for an average of 3.39 months after their
baseline visit to the pharmacy. The impact of the MMR service for the intervention group was
assessed by evaluating the outcomes of the recommendations submitted by the clinical pharmacist
to resolve the identified TRPs, physicians’ acceptance of the recommended interventions, and the
effect of the intervention on certain clinical outcomes: blood glucose levels, blood pressure, and
triglyceride levels. Follow-up assessment of the control group included evaluating the outcomes of
the identified TRPs (identified and corrected by physicians without any input from the clinical phar-
macist) and comparing glucose level, blood pressure, and triglyceride-level results with baseline val-
ues. No significant differences in mean number of medical conditions (3.7 vs 3.42, p=0.134), mean
number of medications (4.51 vs 4.96, p=0.135), or mean number of TRPs per patient (5.55 vs 5.17,
p=0.42) were observed at baseline in the intervention group versus the control group. Follow-up
results revealed a high acceptance rate of recommendations by the physicians (94%). Regarding out-
comes of TRPs, almost 70% of the identified TRPs in the intervention group were resolved or
improved compared with 2% in the control group (p<0.001). Significant differences were found
between the intervention group versus control group with regard to mean  SD glucose levels
(99.08  9.66 vs 115.48  17.34, p<0.001), blood pressure (110.36/81.55  9.45/3.91 vs 125.0/
88.73  10.34/4.12, p<0.001), and triglyceride levels (148.53  15.98 vs 170.74  6.26, p=0.001).
CONCLUSION The MMR service resulted in a significantly lower number of TRPs and significantly
improved clinical outcomes, and it was highly accepted by the physicians.
KEY WORDS community pharmacy, pharmaceutical care services, medication management review,
Jordan.
(Pharmacotherapy 2016;36(10):1075–1086) doi: 10.1002/phar.1833
1076 PHARMACOTHERAPY Volume 36, Number 10, 2016

Medication use in the outpatient setting has needed, considering the absence of the family
increased substantially over the past few doctor system,5 patients resorting to using differ-
years.1, 2 Unlike the inpatient setting, in which ent medical specialists in the management of
the prescribing and distribution of medication is their different health ailments,5 deficiencies
more controlled by health care providers, of standard treatment guidelines,5 high rates of self-
patients in the community setting are becoming medication with both prescription-only and over-
increasingly responsible for medication adher- the-counter drugs,18, 19 poor medication adher-
ence, monitoring, and reporting.3 Despite medi- ence,20 suboptimal patient education,21 and absence
cal evidence supporting the use of medications of obligatory continuing education programs for
for a variety of chronic diseases, inappropriate pharmacists.22 The community pharmacy in Jor-
use of medications is still common and rarely dan is a health care setting that provides easy
evaluated and controlled in community pharma- access for patients, but due to suboptimal phar-
cies.4 The term “treatment-related problems” macy practice and inactive regulations, it remains
(TRPs) has been used commonly in many an accessible source of medication that is not well
research studies5–7 and is defined as an event or controlled. Clinical pharmacists are in an ideal
circumstance involving patient treatment that position to deliver pharmaceutical care services
actually or potentially interferes with an opti- that will improve patients’ use of medications and
mum outcome for a specific patient.7 TRPs have related health care outcomes.
been connected with pain, suffering, and even The aim of this study was to assess the impact
death.8, 9 The financial burden and detrimental of an MMR service on TRPs and certain clinical
clinical outcomes associated with these problems outcomes in outpatients who visited two com-
still needs resolution.9, 10 Hence addressing this munity pharmacies.
issue by establishing effective pharmaceutical
care services in community pharmacies is vital.11 Methods
Pharmacists are positioned to assume a greater
role in preventing and treating TRPs in the com- Study Design, Setting, and Patient Population
munity.6 The pharmacist’s role as the detector,
interceptor, and reporter of TRPs to physicians This was a prospective randomized controlled
is an area that needs to be explored further. trial conducted at two community pharmacies in
According to the Joint Commission of Pharmacy Amman, Jordan. On average, each community
Practitioners, provision of pharmaceutical care pharmacy serves 60–70 patients per day. Patients
should revolve around the “patient-care pro- were asked to visit only the study pharmacy
cess,” where pharmacists use a patient-centered from which they were recruited during the study
approach in collaboration with other health care period. Only one clinical pharmacist was
providers to optimize medication use and involved in this study. Ethics approval was
patient health outcomes.12 Different models of obtained from a local ethics committee.
medication management reviews (MMRs) Inclusion criteria were age older than
around the world have been established. Medica- 18 years, presence of at least one chronic medi-
tion therapy management in the United States,13 cal condition, and prescribed at least three medi-
clinical medication review in the United King- cations. In the control group, patients with a
dom,14 and MMR in Australia15 are good exam- life-threatening TRP (defined as one that could
ples. These models have the goal of maximizing result in a fatal outcome if the current practice
patient benefit from their medication regimen was continued) or serious major problems that
and preventing TRPs through a team approach could not be ignored were excluded from the
involving the patient’s physician and the phar- study, and their physicians were contacted. All
macist.10, 13, 16, 17 In Jordan, similar models are patients who agreed to participate signed an
informed consent form.

*Address for correspondence: Salah Aburuz, College of Study Intervention

Pharmacy, King Saud bin Abdulaziz University for health
Sciences. National Guard Street, Riyadh, 11481, Saudi Ara- Eligible patients were randomized into two
bia; Department of Biopharmaceutics & Clinical Pharmacy, groups: the intervention and control groups.
Faculty of Pharmacy, The University of Jordan, Queen
Rania Street, Amman, 11910, Jordan: email: aburuz@g- Randomization was completed according to a
mail.com; [email protected]. computer-generated randomization table. Physi-
Ó 2016 Pharmacotherapy Publications, Inc. cians involved in the management of the
 COMMUNITY-BASED MEDICATION MANAGEMENT REVIEW SERVICE Basheti et al 1077

recruited patients were invited to participate in TRP Assessment and Documentation, and
the study, and those who agreed provided oral Patient Follow-up
consent. In the case of a physician who declined,
another physician was contacted until all The complete database for each patient was
patients were allocated with a physician who analyzed to identify TRPs for patients in both
would receive the pharmacist’s recommenda- groups (intervention and control) by using the
tions. Participating physicians received the clini- TRP classification system.23 TRPs were then
cal pharmacist’s recommendations for the recorded in a subjective, objective, assessment,
patients in the intervention group only. and plan (SOAP) format in the consultation
The clinical pharmacist conducted a baseline notes. For each patient in the intervention
assessment MMR for patients in both the inter- group, the consultation note was sent to the
vention and control groups to determine the physician. Patient-level TRPs (any TRP that
prevalence and type of TRPs; however, recom- could be resolved through patient education and
mendations regarding the identified TRPs were counseling) were resolved directly with the
only submitted to the physicians of patients in patient by the clinical pharmacist.
the intervention group. The impact of the MMR Patients in both groups were followed up, and
service for the intervention group was then phone calls were conducted by the clinical phar-
assessed by evaluating the outcomes of the rec- macist to remind the patients of their second
ommendations submitted by the clinical pharma- visit to the pharmacy 3 months after the baseline
cist to resolve the identified TRPs, physicians’ visit. Data collection was conducted on week-
acceptance of the recommended interventions, days from 10 A.M. to 5 P.M. Data collection
and the effect of the intervention on certain required about 6 months (recruitment plus a fol-
clinical outcomes: blood glucose levels, blood low-up period of 3 months) in each of the two
pressure, and triglyceride levels. Follow-up participating pharmacies. Follow-up assessments
assessment of the control group included evalu- occurred in the pharmacy settings during the
ating the outcomes of the identified TRPs (iden- patients’ visits; phone calls were made to set fol-
tified and corrected by physicians without any low-up appointments for the patients. Assess-
input from the clinical pharmacist) and compar- ments involved number and type of TRPs, as
ing glucose level, blood pressure, and triglyc- well as blood pressure, blood glucose, and
eride-level results with baseline values. triglyceride-level values. For patients in the con-
trol group, after the completion of the study,
consultation notes were sent to the physicians,
Data Collection and Instruments Used and patient-level TRPs were delivered by the
A validated pharmaceutical care tool23 was used pharmacist (for ethical considerations).
for the collection of patients’ data that consisted of
general patient information (demographic and Study Outcome Measures
administrative information), current acute and
chronic medical problems, current drugs, history For patients in the intervention group, physi-
of previous diseases and drugs, family history, life- cians’ acceptance of the clinical pharmacist’s rec-
style, social history, allergies, vital signs, physical ommendations and number of TRPs corrected
examination data, laboratory data, and drug serum were assessed. For patients in the intervention
concentration and diagnostic test results. This tool and control groups, the prevalence and nature of
was used to collect data for all patients, at baseline TRPs identified; significance of the identified
and at follow-up, through patient interview and by TRPs; therapeutic outcomes in terms of the
using the patient’s medical records obtained from number of TRPs resolved, improved, drug added
the patient’s physician. Baseline values of blood to prevent future morbidity (prevented), not
pressure, blood glucose level, and triglyceride level changed, or worsened; and blood pressure,
were assessed by using commercially available blood glucose level, and triglyceride-level values
instruments to assess disease control. For blood were compared at baseline and follow-up.
pressure measurement, a mercurial sphygmo-
manometer was used (ESMES, Model TM-101 Classification of TRPs
Desk Type, Taipei, Taiwan). The Accutrend GCT
meter (Roche Diagnostics, Mannheim, Germany) Classification of TRPs was completed based
was used to measure glucose and triglyceride on the previously published tool23 that
levels. divided the TRPs into seven main categories:
1078 PHARMACOTHERAPY Volume 36, Number 10, 2016

unnecessary drug therapy, untreated conditions Comparisons Drug Interactions Facts) was used
that require drug therapy, efficacy, safety, inap- for identifying clinically important drug-drug
propriate knowledge, inappropriate adherence, interactions.
and miscellaneous problems. The miscellaneous
category included eight subcategories of TRPs
Outcomes of TRPs
that cannot be classified under any other cate-
gory: need for additional or more frequent moni- Outcomes of TRPs were classified into five
toring, need for additional diagnostic test, need categories: resolved (therapeutic outcome was
for consultation, the chosen medication is not achieved), improved (therapeutic outcome was
cost-effective, other dosage regimen issues due improved but not fully achieved), prevented
to inappropriate timing or wrong dosage form, (drug added to prevent future morbidity), no
other interaction issues, administering errors, change (the therapeutic outcome was not
and dispensing errors. improved or changed), and worsened (the thera-
TRP severity was classified into the following peutic outcome was worsened).
categories: minor (one that if omitted would
probably have no effect on patient’s outcome),
Medication Adherence
moderate (one that if the current practice con-
tinued could have an undesirable effect on Adherence to medications was assessed using
patient’s outcome), and major (one that if the a validated scale.25 The questionnaire was trans-
current practice continued could be detrimental lated and validated.7 The questionnaire is com-
to patient’s outcome).24 All TRPs related to inap- posed of five items asking patients how often
propriate adherence and inappropriate knowl- during the last month they forgot to take their
edge were considered major. Most of the medication, skipped their medication, stopped
inappropriate monitoring requirements were also their medication when they felt better, stopped
considered major, especially when the last moni- their medication when they felt worse, or
toring test was more than 3 years ago and the stopped their medication when they experienced
patient’s condition seems to be uncontrolled. All a side effect. The questionnaire was scored by
TRPs were assigned a severity before the report using the following scale: 0 (never), 1 (rarely), 2
with recommendations was written to the doc- (sometimes), 3 (often), and 4 (always). Patients
tor. The classifications of TRPs were initially were considered to be nonadherent if their total
made by the clinical pharmacist who conducted adherence score was 1.0 or more.
the intervention and then approved by study
investigators. The TRPs were prioritized when
Statistical Analysis
more than one was identified for the same
patient, based on the severity of the TRPs. Data were coded and entered using Statistical
Package for Social Sciences (SPSS), v.17. Cate-
gorical data were expressed as numbers and per-
Identification of TRPs
centages, and continuous data were expressed as
A systematic approach was used to identify means and standard deviations. Group differ-
TRPs that was successfully implemented in pre- ences (between the intervention and control
vious studies.23 Appropriateness of dosing regi- groups) were examined by using an independent
men was checked by comparing dosages with sample t test for continuous independent vari-
evidence-based guidelines or using drug infor- ables. The v2 square analysis was used to ana-
mation references such as Lexi-Comp’s Drug lyze categorical independent variables. A p value
Information Handbook. Patients’ clinical charac- less than 0.05 was considered to indicate a sta-
teristics were taken into account when choosing tistically significant difference.
dosage regimens. Actual adverse drug reactions Because all data were classified using the vali-
were identified by conducting a complete review dated classification system by one researcher,23
of the patient’s symptoms and by evaluating the it was not considered necessary to perform inter-
patient’s clinical data. Potential adverse drug rater or intra-rater variability analysis.
reactions were also assessed by identifying
patients who were at risk but were not receiving
Sample Size
prophylactic treatment (e.g., patients not receiv-
ing prophylaxis for nonsteroidal antiinflamma- The data from the first 20 patients were used
tory drugs–induced ulcer). I-Facts (Facts and to estimate the minimum required sample size.
 COMMUNITY-BASED MEDICATION MANAGEMENT REVIEW SERVICE Basheti et al 1079

The mean difference in TRPs that were resolved, TRPs. None of the patients included in the
improved, or prevented between the intervention study were lost to follow-up during the study
and control group was 2 (SDs 1.9 and 0.3, period (Figure 1).
respectively). Setting a at 0.05 and using a Of 47 physicians contacted during the study
power of 90%, the minimum required sample period, 20 (42.6%) agreed to participate; the
size to obtain a significant difference was 60 remaining 27 refused to participate due to time
subjects in each group. Assuming a 20% dropout constraints or elected not to be involved in the
rate, a total of 150 patients was required for the service. Specialists who agreed to participate
study. were three pulmonologists, four internists, two
general practitioners, two cardiologists, two
oncologists, one rheumatologist, two endocrinol-
Results
ogists, a family physician, a neurologist, a
Between September 2009 and June 2010, a nephrologist, and a gastroenterologist.
total of 57 patients were recruited from the The 160 patients who participated were
first pharmacy; 11.7% of all patients visiting recruited and randomized into the intervention
the pharmacy were eligible for the study, and (82 patients) and control (78 patients) groups.
~19% of the eligible patients agreed to partici- Baseline demographic and clinical characteristics
pate in the study. A total of 103 patients were of the study patients were similar between the
recruited from the second pharmacy; 8.6% of groups (Table 1). Although statistically not sig-
all patients visiting the pharmacy were eligible nificant, the comparison of obesity between the
for the study, and 40.8% of the eligible patients groups was clinically significant because the
agreed to participate in the study. Some intervention group had more than twice as many
patients refused to participate due to privacy obese patients as the control group, and the con-
reasons. Five patients were excluded from the trol group had almost twice as many morbidly
study’s control group due to life-threatening obese patients.

Eligibility assessment
215 patients visited the community pharmacies during study
enrollment period. All patients were assessed for inclusion
criteria.

50 patients refused to participate.

Reasons included:
30 due to lack of time
20 refused to provide a reason

165 patients met inclusion criteria and were recruited and

randomized into intervention and control groups

Intervention group Control group

Baseline assessment Baseline assessment
n=82 n=83

5 patients were excluded

at baseline due to life
threatening treatment-
related problems

3-months follow-up assessment 3-months follow-up assessment

n=82 n=78

Figure 1. Consolidated Standards of Reporting Trials diagram showing recruitment and retention of patients in the
intervention group (n=82) and control group (n=78) during the study period.
1080 PHARMACOTHERAPY Volume 36, Number 10, 2016
Table 1. Baseline Demographic and Clinical Characteristics of the Study Patients
All patients Intervention group Control group
Characteristic (n=160) (n=82) (n=78) p value
Proportion of patients 100% 51.30% 48.80%
Age, yrs 53.01  15.39 53.57  16.03 52.41  14.77 0.634
Male 76 (47.5) 39 (47.4) 37 (47.6) 0.987
Education
None 23 (14.4) 12 (14.6) 11 (14.1) 0.807
Preliminary 21 (13.1) 11 (13.4) 10 (12.8)
Secondary 4 (2.5) 3 (3.7) 1 (1.3)
Tertiary 33 (20.6) 18 (22) 15 (19.2)
Diploma 33 (20.6) 18 (22) 15 (19.2)
University degree 46 (28.8) 20 (24.4) 26 (33.3)
BMI categorya
Underweight 2 (1.3) 0 (0) 2 (2.6) 0.124
Normal weight 41 (25.6) 19 (23.2) 22 (28.2)
Overweight 70 (43.8) 36 (43.9) 34 (43.6)
Obese 30 (18.8) 21 (25.6) 9 (11.5)
Morbid obesity 18 (11.3) 7 (8.5) 11 (14.1)
BMI 27.97  5.40 28.17  4.72 27.75  6.06 0.623
No. of acute and chronic 3.56  1.15 3.7  1.13 3.42  1.57 0.134
medical problems
No. of medications 4.73  1.79 4.51  1.84 4.96  1.72 0.135
Most frequent medical conditions
Hypertension 99 (61.9) 41 (50) 58 (74.4) 0.170
Diabetes mellitus 80 (50) 45 (54.9) 35 (44.9)
Hyperlipidemia 61 (38.1) 34 (41.5) 27 (34.6)
Cardiovascular disease risk 49 (30.6) 23 (28.1) 26 (33.3)
Obese or morbid obesity 48 (30) 28 (34.2) 20 (25.6)
Most frequent drug classes
Thiazide diuretics 95 (59.4) 32 (39) 53 (68) 0.003
Biguanides 67 (41.9) 39 (47.6) 28 (35.9)
b-Blockers 54 (33.8) 17 (20.7) 37 (47.4)
Aspirin 50 (31.3) 16 (19.5) 34 (43.6)
Sulfonylureas 47 (29.4) 26 (31.7) 21 (26.9)
Monitoring parameters
Blood pressure 119.17/84.05  12.98/4.25 121.36/84.58  13.83/4.43 0.576
Blood glucose level 121.65  27.26 118.55  28.4 0.331
Triglyceride level 197.85  43.67 188.19  60.34 0.471
Data are mean  SD values no. (%) of patients.
BMI
a
= body mass index.
BMI categories were classified as follows26: underweight = BMI < 18.5 kg/m2; normal weight = 18.5–24.9 kg/m2; overweight = 25.0–
29.9 kg/m2; obese (class I) = 30.0–34.9 kg/m2; obese class II = 35.0–39.9 kg/m2; morbid obesity (obese class III) = > 40 kg/m2.

The mean  SD number of medical condi- medication adherence. Overall, ~13% of TRPs
tions among study patients was 3.56  1.15, were related to the need for additional or combi-
and the mean  SD number of medications used nation therapy. Poor knowledge about nonphar-
was 4.73  1.79 (Table 1). A total of 859 TRPs macologic therapy and lifestyle changes accounted
were identified during the study period, with a for ~12%. The need for additional monitoring
mean  SD number of 5.37  3.01 TRPs for was also common (13%; Table 2).
each patient. The most commonly identified Table 3 presents the type and frequency of
TRP categories were efficacy, inappropriate the TRPs identified in this study in relation to
adherence, miscellaneous problems, and inap- the most frequent medical conditions and drug
propriate knowledge (Table 2). No significant classes identified. Lack of adherence con-
differences were found in the frequency of TRPs tributed mostly to the TRPs identified for
between the groups, except for the categories of patients with hypertension. The need for addi-
unnecessary drug therapy and efficacy; a trend tional therapy was the most frequent TRP for
toward differences in inappropriate adherence patients with hyperlipidemia and asthma,
was also shown. whereas the need for additional monitoring was
A closer evaluation of the identified TRPs the most frequent TRP for patients with dia-
showed that ~16% of TRPs were related to betes mellitus.
 COMMUNITY-BASED MEDICATION MANAGEMENT REVIEW SERVICE Basheti et al 1081
Table 2. Treatment-Related Problems Identified at Baseline
TRPs in the
TRPs in all intervention TRPs in the
patients group control
TRP (n=859) (n=455) group (n=404) p valuea
Percentage of total TRPs 100 53 47 –
No. of total TRPs/patient, mean  SD 5.37  3.01 5.55  2.635 5.17  3.36 0.42
Unnecessary drug therapy 75 (8.73) 29 (6.37) 46 (11.39) 0.03
Drug use without an indication 50 (5.82) 19 (4.18) 31 (7.67) –
Addiction or recreational drug use 2 (0.2) 2 (0.44) 0 (0)
The patient treatment should 1 (0.1) 0 (0) 1 (0.25)
be stepped down
Duplication 20 (2.33) 7 (1.54) 13 (3.22)
Treating avoidable adverse reaction 2 (0.2) 1 (0.22) 1 (0.25)
Untreated conditions 84 (9.78) 41 (9.01) 43 (10.64) 0.91
Untreated conditions that require 84 (9.78) 41 (9.01) 43 (10.64)
drug therapy
Efficacy 200 (23.28) 121 (26.59) 79 (19.55) 0.01
More effective drug available 10 (1.16) 3 (0.66) 7 (1.73) –
or recommended
Additional or combination therapy 111 (12.92) 66 (14.51) 45 (11.14)
is required
Efficacy dosage regimen issue 78 (9.08) 51 (11.21) 27 (6.68)
Efficacy interaction issue 1 (0.1) 1 (0.22) 0 (0)
Safety 37 (4.31) 24 (5.28) 13 (3.22) 0.18
A current drug is contraindicated 0 (0) 0 (0) 0 (0) –
or unsafe
Safer drug is recommended 0 (0) 0 (0) 0 (0)
High risk for adverse drug reaction 1 (0.1) 0 (0) 1 (0.25)
Allergic reaction or undesirable effect 0 (0) 0 (0) 0 (0)
Safety dosage regimen issue 31 (3.61) 19 (4.18) 12 (2.97)
Safety interaction issue 5 (0.58) 5 (1.1) 0 (0)
Inappropriate knowledge 120 (13.97) 68 (14.95) 52 (12.87) 0.1
Patient not instructed or does not 19 (2.21) 12 (2.64) 7 (1.73) –
understand important information
regarding medication
Patient not instructed or does not 101 (11.76) 56 (12.31) 45 (11.12)
understand important information
regarding nonpharmacologic therapy
Inappropriate adherence 179 (20.84) 80 (17.58) 99 (24.51) 0.07
Problem in adherence to medication 141 (16.41) 63 (13.85) 78 (19.31) –
Drug not available 1 (0.1) 0 (0) 1 (0.25)
Problem with adherence to self-care 37 (4.31) 17 (3.74) 20 (4.95)
activities or nonpharmacologic therapy
Miscellaneous 164 (19.09) 92 (20.22) 72 (17.82) 0.24
Need for additional or more 108 (12.57) 54 (11.87) 54 (13.37) –
frequent monitoring
Need for additional diagnostic test 25 (2.91) 14 (3.08) 11 (2.72)
Need for consultation 13 (1.51) 12 (2.64) 1 (0.25)
The chosen drug is not cost-effective 0 (0) 0 (0) 0 (0)
Other dosage regimen issues 17 (1.98) 12 (2.64) 5 (1.24)
due to inappropriate
timing or wrong dosage form
Other interaction issue 0 (0) 0 (0) 0 (0)
Administering errors 0 (0) 0 (0) 0 (0)
Dispensing errors 1 (0.1) 0 (0) 1 (0.25)
Data are no. (%) of TRPs unless otherwise indicated.
TRP = treatment-related problem.
a
The t test was used to determine the difference in mean TRPs for each category. No significant difference was found between the groups in
the average number of total TRPs.
1082 PHARMACOTHERAPY Volume 36, Number 10, 2016
Table 3. Types of Treatment-Related Problems for the Most Frequent Medical Conditions and Drug Classes Identified
Medical condition or drug class
(no. [%] of total TRPs [n=859]) Type of TRP No. (%) of TRPs
Medical condition
Hypertension (162 [18.9]) Lack of adherence to lifestyle changes 74 (45.7)
Need for additional monitoring 20 (12.4)
Need for additional therapy 16 (9.9)
Lack of adherence to medication 16 (9.9)
Lack of knowledge about lifestyle changes 5 (3.1)
Hyperlipidemia (79 [9.2]) Need for additional therapy 19 (24.1)
Efficacy dosage regimen issue 13 (16.5)
Untreated condition 11 (13.9)
Safety dosage regimen issue 10 (12.7)
Lack of knowledge about lifestyle changes 9 (11.4)
Asthma (92 [10.7]) Need for additional therapy 39 (42.4)
Efficacy dosage regimen issue 19 (20.7)
Need for additional monitoring 12 (13.1)
Lack of knowledge about lifestyle changes 7 (7.6)
Diabetes mellitus (149 [17.3]) Need for additional monitoring 56 (37.6)
Efficacy dosage regimen issue 21 (14.1)
Need for additional therapy 19 (12.8)
Safety dosage regimen issue 10 (6.7)
Lack of adherence to lifestyle changes 10 (6.7)
Obesity/Morbid obesity (58 [6.8]) Lack of knowledge about lifestyle changes 42 (72.4)
Untreated condition 12 (20.7)
Efficacy dosage regimen issue 4 (6.9)
Drug class
Thiazide diuretics (60 [7.0]) Inappropriate adherence 38 (63.3)
Need for combination therapy 10 (16.7)
Duplication 5 (8.3)
Safety dosage regimen issue 5 (8.3)
Biguanides (46 [5.4]) Efficacy dosage regimen issue 22 (47.8)
Inappropriate adherence 12 (26)
Need for combination therapy 8 (17.4)
Drug use without indication 2 (4.4)
Sulfonylureas (41 [4.8]) Need for combination therapy 16 (39)
Safety interaction issue 12 (26.8)
More effective drug available 5 (12.2)
Inappropriate adherence 4 (9.7)
Short-acting b2-agonists (50 [5.8]) Need for combination therapy 25 (50)
Efficacy dosage regimen issue 14 (28)
Inappropriate knowledge 11 (22)
Fibrates (28 [3.3]) Efficacy dosage regimen issue 13 (46.4)
Need for combination therapy 8 (28.6)
Inappropriate adherence 5 (17.9)
TRP = treatment-related problem.

The most common drug classes associated For the intervention group, the acceptance
with the identified TRPs were thiazide diuretics, rate among the contacted physicians was very
biguanides, sulfonylureas, b2-agonists, and high (94%). Significant differences were found
fibrates (Table 3). Significant differences between the intervention and control groups
between the intervention and control groups with regard to TRP outcomes at follow-up.
(p=0.003) were noted. Patients in the intervention group had signifi-
The most common types of interventions cantly more TRPs resolved or improved (~70%)
required to resolve the identified TRPs were the and significantly more drugs added, whereas in
need to add a drug, need for counseling on the control group, significantly more patients
adherence, need for more frequent monitoring, (~87%) had no changes made to their TRPs
and the need for patient education (Table 4). (Figure 2).
Most (90.3%) of the identified TRPs were classi- For the intervention group, ~0% of the identi-
fied as major problems; 9.2% were moderate fied TRPs were resolved or prevented (drug was
problems (Table 5). added). Physicians were not able to resolve the
 COMMUNITY-BASED MEDICATION MANAGEMENT REVIEW SERVICE Basheti et al 1083
Table 4. Types of Interventions Recommended by the Outcomes of Treatment-Related Problems
Clinical Pharmacists to Resolve the Identified Treatment- *

Percentage of participants (N%)

100
Related Problems 87.4
80
No. (%) of all
treatment-related 60 *
Intervention typea problems (n=859) 43
*
40
Adding another drug 191 (22.2) 26.2
Counseling on adherenceb 172 (20.0) 20
19 *
9.2 5.7
More frequent monitoring 140 (16.3) 0.5 1.5 3.9 0
Patient educationb 126 (14.7) 0
Ceasing a drug 75 (8.7) Resolved Improved No change Worsened Drug added
Increasing the frequency 44 (5.1) Intervention Control
Changing the drug 31 (3.6)
Changing the drug 19 (2.2) *Statistically significant differences between the intervention and control groups,
p value <0.001, χ2 test.
administration time
Decreasing the dose 16 (1.9) Figure 2. Outcomes of treatment-related problems in the
Increasing the dose 16 (1.9) intervention group (n=82) and control group (n=78) at
Decreasing the frequency 16 (1.9) study follow-up.
Need for consultation 13 (1.5)
a
In accordance with the Jordanian health care system, all of the
interventions in this table except for counseling on adherence and
by physicians without any input from the clini-
patient education need to be performed by physicians.
b
cal pharmacist). These results indicate that the
This intervention can be performed by community pharmacists. intervention group received a benefit that was
40 times higher than the control group regard-
Table 5. Types and Frequencies of Treatment-Related
ing the TRPs identified and corrected.
Problems According to Clinical Significancea No significant differences were observed in
patients’ glucose levels, blood pressure readings,
No. (%) of treatment-related
problems and triglyceride levels between the intervention
Treatment-related
problem Major Moderate Minor
and control groups at baseline. After an average
of 3.39 months, follow-up assessment showed
Unnecessary drug 60 (80.0) 12 (16.0) 3 (4.0)
therapy (n=75)
significant differences between the intervention
Untreated condition 77 (91.7) 7 (8.3) 0 (0.0) group versus control group with regard to blood
(n=84) pressure readings (110.36/81.55  9.45/3.91 vs
Efficacy (n=200) 175 (87.5) 25 (12.5) 0 (0.0) 125.0/88.73  10.34/4.12, p<0.001), blood glu-
Safety (n=37) 21 (56.8) 16 (43.2) 0 (0.0) cose levels (99.08  9.66 vs 115.48  17.34,
Inappropriate knowledge 118 (98.3) 2 (1.7) 0 (0.0)
(n=120)
p<0.001), and triglyceride levels (148.53 
Inappropriate adherence 179 (100.0) 0 (0.0) 0 (0.0) 15.98 vs 170.74  6.26, p=0.001).
(n=179)
Miscellaneous problems 146 (89.0) 17 (10.4) 1 (0.6)
(n=164) Discussion
All treatment-related 776 (90.3) 79 (9.2) 4 (0.5)
problems (n=859)
To our knowledge, this randomized controlled
a
Minor = one that if omitted would probably have no effect on
study is the first to show that the MMR service
patient’s outcome; moderate = one that if current practice contin- delivered by a clinical pharmacist can lead to
ued could have an undesirable effect on the patient’s outcome; significant improvements in clinical outcomes
major = one that if current practice continued could be detrimen- including blood pressure, glucose levels, and
tal for the patient’s outcome. Examples of the clinical significance
of the identified treatment-related problems include the following: triglyceride levels. Moreover, the study confirms
omeprazole used without a medical indication in a patient with no the need for this service in Jordan, considering
risk of nonsteroidal antiinflammatory drugs–induced ulcer, no fre- the high number of major TRPs identified (aver-
quent heartburn, and no medical insurance (a drug without a med-
ical indication of major significance); aspirin for cardiovascular age of 4.9 major TRPs per patient). Participating
protection used at a dose of 325 mg/day when it is recommended physicians showed a high acceptance rate of the
to use 100 mg/day to minimize adverse effects (safety dose regimen of the pharmacist’s recommendations, leading to
issue of moderate significance).
the resolution, improvement, or prevention of
80% of the identified TRPs.
remainder of the TRPs due to failure to reach Pharmaceutical care has become a dominant
the patients and implement the required inter- form of practice for thousands of pharmacists all
ventions. In the control group, only 2% of the over the world.13, 15 Most of the studies on
TRPs identified by the clinical pharmacist at pharmaceutical care interventions were con-
baseline were corrected (identified and corrected ducted in the United States,13 Europe,10 and
1084 PHARMACOTHERAPY Volume 36, Number 10, 2016

Australia,4 and they all showed a positive impact and overseas.31 These, in addition to asthma,
on patients’ health. However, these interventions were also the most frequent diseases associated
were conducted in country-specific health care with the identified TRPs.6 Many of the identified
systems, and it may not be easily translated and TRPs were associated with untreated conditions,
implemented in other health care systems, such some of which were serious conditions. Diabetes
as in Jordan. This study showed that the MMR mellitus was an example. Patients were found to
service can be translated and implemented in interpret their symptoms in a wrong way; most
the Jordanian health care system. The environ- of them were not seeking medical attention
ment of the community pharmacy in Jordan is unless serious disabling symptoms appeared.
distinctive because most patients with a health Specialists were found to be unaware or less
ailment prefer to visit the community pharmacy cautious about medical conditions that were not
first27 to save the time and cost of a doctor related to their specialties.
visit.19 Many of the regulations and laws in Jor- The most commonly used medications by the
dan are still inactive, leading to the dispensing study participants were thiazide diuretics, bigua-
of most medications without a medical prescrip- nides, sulfonylureas, b-blockers, and aspirin.
tion,28 leading to major implications for the These were clinically correct, evidence-based
safety and effectiveness of the pharmacotherapy medications for the health ailments experienced
used in this country. by the patients in this study. These medications
In a previous study conducted in an inpatient were also in concordance with previous results
setting in Jordan, the mean  SD number of TRPs investigating the most commonly used medica-
identified by clinical pharmacists was 9.35  5.0, tions by older patients.6, 31, 34
with an average of 8  3.9 medical conditions for This study has certain limitations including the
each hospitalized patient.7 As anticipated, such a restricted time and space available to the commu-
lower number of TRPs per medical condition is nity pharmacist for interviewing the patients.
due to the regular follow-up and strict control that Only one clinical pharmacist was involved in con-
hospitalized patients usually receive compared ducting the assessments for all patients, which
with that in the community setting. Similar to our although it prevents variability in the recommen-
study, results from the community pharmacy set- dations, could limit the generalizability of the
tings in Michigan showed that the mean number study. The time required by the clinical pharma-
of TRPs identified by clinical pharmacists was cist for the identification of each TRP and the
~9.8, with an average of six medical conditions proportion of self-medication and use of alterna-
(an average of 1.65 TRPs per medical condi- tive and complementary medicines were not
tion),29 which is comparable with the results from assessed. Not all recommendations approved by
this study. It is important to note that comparing physicians were implemented due to the inability
the frequency of TRPs identified in this study with to contact some patients during the study. Rec-
other studies is not simple because both the defi- ommendations rejected by physicians were not
nition of TRPs and the patient population differ documented in this study. Such data would allow
greatly from study to study. for a better understanding of their practice and
The most common TRPs identified in this why some physicians were resistant to this ser-
study (mainly efficacy, inappropriate adherence, vice. The prevalence and types of TRPs in Amman
miscellaneous problems, and inappropriate might not reflect the situation in other cities in
knowledge) are in concordance with previous Jordan because most specialists practice in
studies.7, 30–33 Poor patient education repre- Amman (the capital of Jordan). Certain statistical
sented the most common TRP in those previous differences between the intervention and control
studies. With ~84% of our study sample showing groups were found at baseline; however, it was
good knowledge and/or adherence to their medi- not expected that these differences affected the
cations, our results are promising. However, results of the study. Patients’ health literacy was
with the goal of having 100% of the population not assessed, which can be an important assess-
showing good adherence and knowledge about ment of medical knowledge and adherence.
medications, more effort is needed in this area. Because multiple TRPs were identified for each
The most common medical conditions that patient, paired data comparisons in future studies
the recruited patients had were hypertension, would be beneficial. The study setting consisted
diabetes, hyperlipidemia, cardiovascular diseases, of only two pharmacies with a small number of
and obesity. These results are comparable with patients. Future studies with larger sample sizes
similar previous studies conducted in Jordan6 are needed to verify the results of this study.
 COMMUNITY-BASED MEDICATION MANAGEMENT REVIEW SERVICE Basheti et al 1085
use in patients on polypharmacy—a prospective randomised
Conclusion controlled trial. BMC Health Serv Res 2016;16(1):145.
12. Joint Commission of Pharmacy Practitioners PPCP, 2014.
A large number of major TRPs were identified Available from https://www.pharmacist.com/sites/default/files/files/
in this study for patients with chronic conditions PatientCareProcess.pdf. Accessed May 6, 2016.
13. Ramalho de Oliveira D, Brummel AR, Miller DB. Medication
visiting two community pharmacies in Jordan. therapy management: 10 years of experience in a large inte-
The MMR service presented an important pro- grated health care system. J Am Pharm Assoc 2010;16(3):185–
spect for better therapeutic outcomes for these 95.
14. Clinical Medication Review- A Practice Guide 2016. Available
patients. Most of the identified TRPs were from http://www.cumbria.nhs.uk/ProfessionalZone/Medicines
resolved, improved, or prevented as a result of Management/Guidelines/MedicationReview-PracticeGuide2011.
the interventions provided by the MMR service, pdf. Accessed April 10, 2016.
15. Australian Government Medicare Australia. Department of
leading to significant improvements in clinical Human Services. Residential Medication Management Review.
outcomes. The physicians showed high accep- Available from http://www.medicareaustralia.gov.au/provider/
tance of the clinical pharmacist’s recommenda- pbs/fifth-agreement/residential-medication-management-
review.jsp. Accessed February 6, 2016.
tions. Follow-up studies based on the standard 16. Wittayanukorn S, Westrick SC, Hansen RA, et al. Evaluation
definition of improvement for each of the medi- of medication therapy management services for patients with
cal conditions identified in this study are cardiovascular disease in a self-insured employer health plan. J
Manag Care Pharm 2013;19(5):385–95.
needed. 17. Bollmeier SG, Theresa TR. Community pharmacy-based
asthma services: current perspectives and future directions.
Acknowledgment Integr Pharm Res Pract 2014;3:1–22.
18. Albsoul-Younes A, Wazaify M, Yousef AM, Tahaineh L.
The authors are grateful to Applied Science Private Abuse and misuse of prescription and nonprescription drugs
University, Amman, Jordan, for the financial support sold in community pharmacies in Jordan. Subst Use Misuse
2010;45(9):1319–29.
granted to cover the publication fee of this research 19. Yousef AM, Al-Bakri AG, Bustanji Y, Wazaify M. Self-medica-
article. tion patterns in Amman, Jordan. Pharm World Sci 2008;30
(1):24–30.
20. Basheti IA, Hait SS, Qunaibi EA, Aburuz S, Bulatova N. Asso-
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